Thursday, July 21, 2011

All about the breech workshop

What a whirlwind weekend...

It began Friday evening with a discussion session. Participants were able to ask questions of Peter and Betty-Anne, as well as share their own experiences with breech birth as either care providers or mothers of breech babies. The conference co-organizer, Penny Lane, opened the session with the stories of her three breech babies. It's an epic story, one that I hope to tell at a later date in more detail. (I might even turn it into a book, it's that fascinating.)

Saturday's workshop was with Dr. J. Peter O'Neill. He began with two hours of instruction and advice about vaginal breech birth. He reviewed the literature, including knowledge gained from the Hannah term breech trial and more recent European studies. He explained the Canadian breech guidelines and how they were created. Finally, he explained the mechanism of breech birth and the various maneuvers to free trapped legs, arms, and heads. Then it was time to do simulations. He and Betty-Anne had each brought a simulation mannequin, complete with a snap-on vulva and snap-on abdomen. You can imagine the wisecracks coming from a room full of birth attendants. ("Hey Rixa, your vulva's hanging out!")

The participants were all writing or typing furiously, trying to catch all of Peter's instruction and commentary. He was a fabulous instructor, and we all came away feeling confident in the skills he had taught us. He has attended about 8,000 births and between 300-400 vaginal breech births. He teaches vaginal breech, among other skills, for the Canadian ALARM courses taught to physicians, midwives, and nurses. A few highlights that I can remember from his workshop:
  • Trust your training and your instincts. Don't blame yourself for "missing" a breech prenatally--it's highly likely you didn't miss it, as babies can flip very late in pregnancy. 
  • Do vaginal breech births with a best friend--in other words, with someone who won't hesitate to tell you when you're not making wise decisions, when you're letting your emotions or your relationship with your client get in the way of the larger clinical picture. 
  • Try to keep your hands off the baby unless absolutely necessary. The more a breech baby is manipulated as it is being born, the more likely it is to do the "What the F#@!" startle reflex (Peter's words), throwing its hands up and its head back.
  • Peter did breech simulations with the mannequins on their backs, not because he feels that is the best or safest way, but because 90% of his patients choose epidurals and are largely unable to move from that position. He emphasized that the women he attends are free to choose any position they desire during labor and birth, whether for cephalic or breech presentations.
  • Pay attention to the language you use. For example, he never uses "maternal exhaustion" in his records. Instead, he writes "inadequate progress despite maximum maternal effort." He feels this keeps women from feeling like they failed if labor just did not progress, and it emphasizes the extraordinary effort that all labors entail. 
  • Don't fall into the trap of extrapolating from cephalic to breech births. What might be fine for a head-down labor might not be for a breech. He wants to see a breech labor begin spontaneously and progress steadily; in general, the time from 5-10 cms should not take much longer than 7 hours. Start-and-stop labors in a breech are a sign for caution and an indication that a vaginal birth might not be the best decision. Deciding to move to cesarean is not a failure. If certain signs suggest trouble, the decision to abandon a vaginal birth is a wise one. 
I have to say that I was beyond thrilled with Peter's workshop. He was approachable, generous, and willing to engage in an open exchange of ideas and experiences. Anyone who can keep a straight face with a room full of midwives talking about placentophagy has got my vote! I think we were all wishing we had him as a physician in our own communities.

Saturday evening was a lecture on upright breech birth by Betty-Anne Daviss. She took an anthropological approach to breech birth and reviewed the history of breech birth and maneuvers. We had booked the room for two hours, but she ended up speaking for just over an hour. We were all exhausted, and to be honest as much as I would have liked to learn more, I was glad to go back to my (not-so-posh) dorm room and rest. Several of us gathered in a lounge, snacked on cookies and Chipotle Grill wraps, and talked late into the night about birth (of course!).

Sunday's workshop was on upright breech birth with Betty-Anne. She spent the morning overviewing the various breech studies and trends in breech birth throughout the US, Canada, and Europe. I enjoyed learning about how she ended up at Dr. Frank Louwen's clinic in Frankfurt, Germany. She is part of his reserach team gathering data on upright (hands & knees) breech births. They are close to submitting their data for publication. I can't wait to read their findings. Preliminary data that Dr. Louwen presented two years ago in Ottawa showed that the upright position leads to fewer feto-maternal complications, fewer abnormal heart rate tracings during pushing stage (due to less cord compression), and lower morbidity.

Betty-Anne also explained in detail the mechanism of upright breech birth. Using a flexible pelvis and cloth doll, she explained step-by-step how a breech baby descends and turns through the maternal pelvis. At that point Gail Tully (of Spinning Babies) jumped up and started illustrating what Betty-Anne was explaining. By the end of the day, we had all sorts of lovely drawings from Gail. I hope she will reproduce them!

The afternoon was spent doing simulated hands & knees breech births with Betty-Anne and Gail. A few things I learned specific to hands & knees positioning:
  • The baby normally presents at the vaginal outlet with the butt transverse and one butt cheek rumping first, rather than facing directly forward.
  • Once the baby has been born to the umbilicus, you should see a line of "cleavage" on the baby's chest. This indicates that the arms are NOT trapped and in a good position to be born. If you don't see this fold of skin, this indicates that one or both hands are behind the head. AT this point the baby's body should be turned and the baby should be facing you straight on. If the baby remains turned sideways, this again is a bad sign, indicating an inability to descend and rotate properly due to trapped arms.
  • "Frank's nudge" (also called the Louwen maneuver) is used once the arms are born and the head is still inside the mother. Often the baby will emerge on its own. But if the head is not born relatively soon--let's say within the next contraction--this maneuver will help the head be born. First ascertain that the baby's head is facing directly forward, rather than turned to the side. If needed, turn the baby's head to face directly posterior (right towards you, since you are looking at the mother's behind as she is on her hands & knees). Use your thumbs or first two fingers and press on the baby's shoulders towards the mother's pubic bone. (Do not press on or near the clavicles, as they are prone to breaking.) This maneuver causes the back of the baby's head to press against the pubic bone and flex forward, freeing the head.

Attending the breech skills workshop this past weekend reinforced the need for open, honest, and respectful collaboration between home and hospital based providers. Dr. O'Neill's approach to helping women was simple: do what is right for mothers and babies, without regard to political or liability concerns. If a home birth transfer occurs while he's at work, he prepares whatever the situation requires (for example, he would prepare the OR and scrub in for an urgent transport). Then he greets the woman with this simple phrase: "What can I do to help?"


  1. I loved reading the last description of the baby's decent. My mother took amazing moment by moment photos of my daughter's birth, and I can see some of the details you described! Awesome.

  2. This sounds like a wonderful workshop.

  3. What were Dr. O'Neill's opinions on the safety/ risks of out-of-hospital breech birth?

  4. It sounds like such a great conference. For some reason what you said last made me want to cry. I so agree, if only the hospital care providers could work hand in hand with home care providers and SUPPORT women with love and respect. That would be wonderful.

  5. I hope they will repeat this conference at other places. Not all of us were able to travel so far at this time, but might be able to make it if it were closer to us.

    Sounds like an absolutely AWESOME and fascinating conference! Here's hoping they bring it near me!

  6. Oh, I forgot to add that Dr. Odent says something similar about breeches.....that if the labor begins spontaneously and proceeds pretty smoothly, all is usually well. He says he starts to worry if labor stops and starts a lot or if progress stops for a significant amount of time. At that point, he believes a cesarean usually results in better outcomes.

    To him it's not about every breech should be vaginal, it's about judicious vaginal breeches...and figuring out which ones are which.

  7. WRM--where are you located?

    We hope to repeat a similar workshop in a year or two. Now that I've organized one, the next time around should be a bit less stressful! I'd also like to co-organize it with a medical school so we can really get in-hospital providers (both residents and physicians/midwives) updated on their vaginal breech skills. We advertised heavily to every hospital and most OB groups in a 200 mile radius, but had disappointing turnout from that sector nevertheless. (Not entirely surprised that that happened, but'd think more people would want to brush up on their vaginal breech skills, since 3% of women at term will carry breech!)

    A lot of the art of breech birth is knowing when to throw in the towel before things get too ugly. There is less tolerance for dysfunctional labor patterns with a breech baby than there is with a head-down baby.

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